Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity L of L: immediate jeopardy, widespreadCorrected Nov 24, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Sep 3, 2025
Have properly installed electrical wiring and gas equipment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 15, 2025
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 29, 2025
Install corridor and hallway doors that block smoke.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 3, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 1, 2025
Have approved installation, maintenance and testing program for fire alarm systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 11, 2025
Have an enclosure around a vertical opening shaft.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 15, 2025
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 15, 2025
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 15, 2025
Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 5, 2025
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 17, 2025
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 8, 2025
Have proper medical gas storage and administration areas.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 18, 2025
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 15, 2025
Have generator or other power source capable of supplying service within 10 seconds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 1, 2025
Meet requirements for the installation and maintenance of electrical systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 18, 2025
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 15, 2025
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 11, 2025
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 15, 2025
Install proper backup exit lighting.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 15, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 3, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 3, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Jul 30, 2025
Have restrictions on the use of portable space heaters.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 11, 2025
Have simulated fire drills held at unexpected times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 11, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jul 30, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jul 30, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jul 30, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jul 30, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 30, 2025
Use approved construction type or materials.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 5, 2025
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 26, 2025
Have exits that are accessible at all times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2025
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 18, 2025
Install an approved automatic sprinkler system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2025
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 11, 2025
Provide primary/alternate means for communication.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 7, 2025
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadCorrected Aug 1, 2025
